ATI RN
Multi Dimensional Care | Exam | Rasmusson Questions
Question 1 of 5
A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?
Correct Answer: A
Rationale: In the scenario of providing oral hygiene for an unconscious client, the priority nursing intervention of positioning the client on one side with the head turned towards you is crucial. This position helps prevent aspiration and facilitates drainage of oral secretions, reducing the risk of choking or aspiration pneumonia. Option B, handling dentures with care, is important but not the priority when compared to ensuring proper positioning for a client who is unconscious. Option C, using gentle techniques for fragile mucosa, is also important but falls secondary to the immediate need for positioning. Option D, having a suction apparatus ready, is essential but should come after ensuring proper positioning to maintain the airway. In an educational context, this question emphasizes the critical thinking skills required in prioritizing nursing interventions based on the client's condition. Understanding the rationale behind each option helps students grasp the importance of assessing and addressing the most urgent needs first to ensure patient safety and well-being.
Question 2 of 5
The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse?
Correct Answer: A
Rationale: The most appropriate response by the nurse is option A) "Ice packs can be used to reduce swelling but should be removed after 20 minutes." This is the correct answer because ice packs are recommended for reducing inflammation and swelling in rheumatoid arthritis. The application of ice helps constrict blood vessels, reduce inflammation, and numb the area, providing pain relief. However, leaving ice packs on for too long can lead to tissue damage or skin irritation, hence the instruction to remove them after 20 minutes. Option B is incorrect because while heat can help with pain relief, it is not recommended for reducing swelling in rheumatoid arthritis. Heat can actually exacerbate inflammation in this condition. Option C is incorrect because high impact exercises like running can worsen joint pain and inflammation in rheumatoid arthritis. Low-impact exercises are generally recommended to maintain joint mobility without causing further damage. Option D is incorrect because leaving ice packs on for up to one hour can lead to adverse effects such as frostbite or skin damage. It is important to follow the recommended guidelines for using ice packs to avoid complications. In an educational context, it is crucial for nurses to understand the appropriate nonpharmacological interventions for managing rheumatoid arthritis symptoms. Providing accurate information to clients can help improve their quality of life and promote effective self-management of their condition. Nurses play a key role in educating clients about the safe and effective use of interventions like ice packs to alleviate pain and swelling associated with rheumatoid arthritis.
Question 3 of 5
A nurse is preparing a community presentation about repetitive motion injuries. Which of the following occupations should the nurse identify as increasing a client's risk for carpal tunnel syndrome?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Elementary school teacher, as this occupation involves a significant amount of repetitive hand movements such as writing on the board, grading papers, and using a computer, all of which can increase the risk of developing carpal tunnel syndrome due to the continuous strain on the wrist and hand muscles. Option B) Nursing assistant involves tasks that also require repetitive movements, but typically not to the same extent as an elementary school teacher, thus making it a less likely choice for increasing the risk of carpal tunnel syndrome. Option C) Assembly line worker is a physically demanding job that may involve repetitive motions, but carpal tunnel syndrome is more commonly associated with occupations that involve fine motor skills and prolonged use of the hands in specific positions, which is less common in assembly line work. Option D) Truck driver, while requiring long hours of driving, does not typically involve the same level of repetitive hand and wrist movements as the other options mentioned, making it less likely to increase the risk of carpal tunnel syndrome. Educationally, it's important for healthcare professionals to understand the specific occupational risks associated with certain professions to provide relevant and targeted education and preventive strategies to individuals at risk. By identifying occupations that pose a higher risk for conditions like carpal tunnel syndrome, nurses can tailor their community presentations to promote awareness and provide practical advice for prevention and early intervention.
Question 4 of 5
A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?
Correct Answer: A
Rationale: The most appropriate intervention for reducing the risk for a friction and shear injury in an intubated and sedated geriatric client is option A, which is to use a mechanical lift to reposition the client every 2 hours. This intervention is crucial as it helps in redistributing the pressure on the client's body, thereby reducing the risk of pressure ulcers due to friction and shear forces. Repositioning the client with a mechanical lift ensures proper body alignment and minimizes the stress on vulnerable areas, such as bony prominences, which are prone to pressure injuries. Option B, elevating the client's head of the bed to 45 degrees, is not the most appropriate intervention for reducing friction and shear injuries in this scenario. While elevating the head of the bed may have other benefits such as improving ventilation, it does not directly address the risk of pressure injuries caused by friction and shear. Option C, postponing the daily bed bath, is also not the best choice as hygiene is important in preventing infections and maintaining the client's skin integrity. Regular hygiene practices should be maintained while implementing appropriate pressure injury prevention strategies. Option D, where the caregiver independently slides the client up in the bed, is not recommended as it can increase the risk of friction and shear injuries. Improper manual handling techniques can cause friction and shear forces on the client's skin, leading to pressure ulcers. In an educational context, understanding the importance of pressure injury prevention strategies is crucial for healthcare providers caring for vulnerable populations. Proper positioning and repositioning techniques, the use of assistive devices like mechanical lifts, and regular skin assessments are essential components of quality care to prevent pressure injuries in immobilized or sedated patients.
Question 5 of 5
A client is in skeletal traction. With the nurse's assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take first is option A) Collect a culture of the purulent fluid. This is crucial as the redness, swelling, and purulent drainage around the pins indicate a possible infection in the area of skeletal traction. Collecting a culture will help identify the specific microorganism causing the infection, which is essential for selecting the most effective antibiotic for treatment. Option B) Cleanse the skin around the pins is incorrect because while maintaining skin integrity is important, addressing the infection by identifying the causative organism takes precedence. Option C) Administer an antibiotic is premature without knowing the specific pathogen causing the infection, as the choice of antibiotic should be guided by culture and sensitivity results. Option D) Instruct the client to complete exercise of the affected extremity is inappropriate at this time as the priority is to address the infection to prevent further complications. Educationally, this question highlights the importance of prioritizing nursing actions based on the assessment findings and understanding the principles of infection control. It also emphasizes the significance of proper wound care, infection management, and the role of diagnostic testing in guiding treatment decisions. Nurses need to have a solid foundation in recognizing signs of infection and implementing appropriate interventions to ensure optimal patient outcomes.